Nokea
The nurse is reviewing the client's medical record.
Procedures
Planned endoscopy at 1300.
The nurse is reviewing the client's medical record. Procedures Planned endoscopy at 1300. The nurse is assisting with the care of a client prior to a blood transfusion. Which of the following actions should the nurse take? Select all that apply.
- A. Witness the client signing a consent for transfusion.
- B. Obtain a large bore IV catheter.
- C. Ensure two nurses confirm the information on the blood label.
- D. Ensure the transfusion tubing is flushed with dextrose 5% in water.
- E. Explain to the client that transfusion reactions are not serious.
Correct Answer: A,B,C
Rationale: Consent ensures informed agreement, a large-bore catheter prevents clotting, and dual verification reduces errors. Dextrose isn't used for flushing, and minimizing reaction severity is inaccurate.
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A nurse is collecting data for a client who is receiving enteral tube feedings. The nurse should identify that which of the following findings is a manifestation of fluid overload?
- A. Weight loss
- B. Decreased blood pressure
- C. Decreased skin turgor
- D. Crackles heard in the lungs
Correct Answer: D
Rationale: Crackles in the lungs indicate pulmonary edema from fluid overload. Weight loss, low blood pressure, or poor skin turgor suggest dehydration, not overload.
A nurse is reinforcing teaching with a client who has a new prescription for gabapentin. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should take this medication with a high-fat meal.
- B. I might feel sleepy while taking this medication.
- C. I need to avoid sunlight while taking this medication.
- D. I can stop taking this medication as soon as my pain goes away.
Correct Answer: B
Rationale: Gabapentin can cause drowsiness, reflecting understanding. Food intake is flexible, sunlight isn't a concern, and stopping needs tapering.
A nurse is caring for a client who is receiving IV fluids with potassium chloride. Which of the following actions should the nurse take?
- A. Monitor the client's cardiac rhythm.
- B. Administer the IV fluids through a large-gauge needle.
- C. Check the client's magnesium levels every 8 hr.
- D. Instruct the client to reduce sodium intake.
Correct Answer: A
Rationale: Potassium chloride can cause arrhythmias, so cardiac monitoring is essential. Needle size varies, magnesium isn't routinely checked, and sodium restriction isn't specific.
A nurse is caring for a client who is postoperative following a cholecystectomy. Which of the following actions should the nurse take to promote comfort?
- A. Encourage the client to ambulate every 2 hr.
- B. Offer the client a high-fat meal.
- C. Apply a heating pad to the client's abdomen.
- D. Provide the client with a pillow to splint the incision during coughing.
Correct Answer: D
Rationale: Splinting the incision with a pillow reduces pain during coughing. Ambulation aids recovery but isn't comfort-focused, high-fat meals are avoided, and heating pads risk complications.
A nurse is caring for a client who has bulimia nervosa. Which of the following actions should the nurse take first?
- A. Observe the client during and after meals.
- B. Suggest that the client assist with meal planning.
- C. Instruct the client about effective coping strategies.
- D. Refer the client to a support group for clients who have eating disorders.
Correct Answer: A
Rationale: Observing during and after meals monitors for purging behaviors, a priority for safety in bulimia. Meal planning, coping strategies, and support groups follow after ensuring immediate safety.